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The Healthy Americans Act was introduced in the 110^th Congress as legislation that seeks to expand medical insurance coverage to all Americans. The bill was pending at the close of the legislative session. Congressman Jim Cooper, D-Tenn., representing the Fifth District is a co-sponsor of the bill and a strong advocate for the principles espoused in the legislation. Congressman Cooper recently discussed the Healthy Americans Act with the Nashville Medical News.

The act will require all citizens to purchase health insurance from a private health insurer. The cost of the premium will be tax deducible for most purchasers. High income individuals will lose the tax deductibility of their healthcare premium payments, while low income individuals will receive a tax funded subsidy to allow them to pay their premium. Employers will no longer be the purchaser of the healthcare or sponsor of employee health insurance, but rather will cash out of their current plans and raise employee wages by the amount of employer contribution to worker health insurance. This will allow employees to individually purchase coverage through a large purchasing pool similar to that used by federal employees and retirees for several decades. The model for benefits is the Federal Blue Cross Blue Shield standard plan currently offered to federal employees. Insurers would be required to place all individuals in the same risk pool and create parity in premiums and vary premiums only by smoking habit, family size, and local health cost index.

An additional source of funding will be in the form of a levy on employers who have not been offering health insurance so that they are no longer free riders on the system. This "pay or play" approach is sometimes called an employer mandate.

NMN: Congressman Cooper, thank you for your time. Describe the essentials of the Healthy Americans Act.
The Healthy Americans Act was sponsored by Sen. Ron Wyden, D-Ore., Sen. Bob Bennett, R-Utah. This bill has the most bipartisan support of any major healthcare legislation in the history of the US Senate. Sixteen senators, eight Democrats and eight Republicans, signed on. Many of them are on the key Senate finance committee.

In the House of Representatives, the lead legislator was Rep. Debbie Wasserman-Schultz, D-Fla., and Rep. Jo Ann Emerson, R-Mo. I wanted those two to lead because women are very powerful not only in healthcare decisions at home but also in healthcare decisions in Congress.

The reason bipartisanship is so important is because the healthcare sector of the economy is $2.1 trillion dollars and no one wants to change the status quo because there are too many people profiting from the current $500 - 700 billion dollar waste in the system. Bipartisanship is also essential because medicine, unlike any other thing we vote on in Congress, has a large emotional component. Patients and doctors have to believe that the system is working in their interest. So, to have the confidence we need, healthcare reform has to work for Republicans, Democrats, Independents and apolitical people. It is essential that we start with this bipartisan base to get the results we need.

The goals of the legislation are to provide health insurance coverage for all Americans with no new taxes and to modernize the current system to make it work better for patients, doctors and payers.

How does the bill propose to achieve those goals?
The way the bill works is to reform the health insurance market so that health insurance companies would have to take anyone who lived in a large geographic area, say Middle Tennessee, or perhaps all of Tennessee. They would not be able to discriminate against patients except on the basis of smoking, family size, or the high cost nature of the particular geographic area. They would not be able to charge a different premium due to health status or age. That's a fundamental change in the system.

It also would reform the system by modernizing the employee-employer health relationship. The current system started in 1942 when wage and price controls were in effect. That's when fringe benefits were invented. Nobody intended them to be as large as they are today. It is the tax inequity that makes that system unsustainable. We are spending $250 billion a year to sustain that system. It's a largely hidden tax which means that most workers today get less in cash raises than they do in fringe benefit increases.

At the same time doctors are working harder than ever but they not getting the benefits of the huge increases in health spending.

What was your role in the legislation?
My role really started almost 15 years ago when I had a rival proposal to the Clinton Health Plan. I knew that I was not the right person to be the lead on the latest version, so I worked with Sen. Wyden to help people understand healthcare and to round up the right cosponsors.

People eventually accepted the seriousness of the bill although they initially did not pay much attention. About 6 months ago it started being on people's radar screen. Now they're paying us a compliment of reacting to the bill, oftentimes against it.

Who are some of the groups that have expressed concerns?
Essentially everybody with a stake is bargaining for better position in the bill. Organized labor does not want to upset their existing collective bargaining agreements and some large employers want to keep offering healthcare to workers. Large employers can have a reasonable risk pool but small employers will never have a large enough risk pool.

Some people on the left want a government health insurance plan to compete with the private sector offerings and that creates difficulties because private sector plans do not believe that government would compete fairly because the government has such large resources. These are some of the concerns that we are hearing, but I think most of these can be accommodated by some sensible process of compromise.

What is the impact on providers?
I will start by saying what the legislation does not do. The Healthy Americans Act plan does not touch Medicare, does not touch the VA, it does not touch programs like that.

It will, I think, make insurance companies much easier to deal with because you won't have the denial of coverage problems that people are facing and I think providers will see simpler paper work and electronic records,

The most important aspect of the legislation is to finally have everybody in America with health insurance coverage so they can go see a doctor. By eliminating the uninsured, doctors and hospitals won't have the bad debt expense they are used to now. One of the most exciting things in the bill and the most controversial is that it would actually end Medicaid. Medicaid is currently a 50-state patchwork quilt. It's underfunded in some states like Tennessee. This would offer poor people private health insurance policies that are subsidized so they would essentially be mainstreamed into regular medicine. Doctors wouldn't have to worry about being paid one-third of their cost for seeing a Medicaid patient. Tennessee probably will never be as generous with their poor people as this health plan will enable us to be, so I think it is a real opportunity for Tennesseans to mainstream our system into the national healthcare system.

I would also like to see the decriminalization of medicine because the government has been so heavy handed in that regard. The government has sometimes been too loose with reimbursement, and often compensated by hammering doctors and hospitals who took advantage of the confusion. I think market competition does a better, faster job of catching wrongdoing, and punishing it without resorting to prosecutors and juries.

What will be the impact on employers?
I think large businesses would be largely untouched. Smaller businesses would fall into two categories. If you are already offering health coverage you'll be asked to increase the cash pay of your workers by the amount that you are spending on their health benefits. The worker can take that cash pay increase and go buy coverage on their own, and buy it from an annual menu much like the one the Federal employees have used the last 40 years.

The health plans that qualify to be on that menu would be good health plans. If you want a more deluxe one, that's fine but you would pay the incremental difference yourself. The employers that are already offering coverage will have the cash pay increase, fringe benefit reduction, and then employees will choose. For employers that are not already offering coverage they will be asked to pay a little bit more because we don't want any free riders on the system.

There will be both an employer mandate and an individual mandate. Everybody will have to buy coverage. It's like driving a car; you can't drive uninsured and you shouldn't be able to go without health insurance. I think you are going to see a better, fairer, system.

Who do you anticipate being in this market?
Right now there are about 2,000 health insurers. The ones that remain will have to be large and capable and fair. No one knows how many of current insurers will want to stay in the business but my guess is that you will see much simpler paperwork, much more uniformity so you don't have this nightmare of paperwork staring you in the face every day. We recognize that the health insurance lobby will feel very strongly about this plan and we are going to have to overcome their resistance and opposition.


Dr. Brent Moody is the founder and Medical Director of the Skin Cancer & Surgery Center in Nashville. Dr. Moody is a Mohs Micrographic Surgeon and skin cancer specialist.

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Healthy Americans Act, Jim Cooper

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